CESSNOCK jail staff failed to transfer an Indigenous inmate to a specialist mental health unit in the three weeks before he was found hanging in a “safe cell” in 2013.

The hesitation in deciding to transfer David William Wotherspoon, 31, to the Mental Health Screening Unit (MHSU) at Silverwater Correctional Centre until his mental health had deteriorated to the extent he was “in crisis” and further “unexpected and unnecessary” delays in implementing the referral were among a number of damning findings handed down by State Coroner Magistrate Michael Barnes on Thursday.

Mr Wotherspoon, 31, was under constant video surveillance in a “safe cell” at Cessnock Correctional Centre’s Mental Health Unit (MHU) at the time he was found unconscious with an apparent ligature around his neck on April 5, 2013.

He never regained consciousness and died nine days later at John Hunter Hospital.

After overseeing a five-day inquest in Newcastle Coroner’s Court in January and February, Mr Barnes delivered his findings on Thursday, highlighting a number of significant flaws that included “inadequately trained” monitoring staff and a failure to conduct a careful risk assessment of what items Mr Wotherspoon could have in his cell.

Mr Barnes said that a Corrective Services officer, who was on her first shift monitoring the 64 cameras in the MHU on the day Mr Wotherspoon died, having been trained that morning, was faced with an “unduly burdensome” task.

Mr Wotherspoon, who had a history of mental illness, self-harm and suicide attempts, was referred to the MHSU at Silverwater, a purpose built mental health facility designed to enable multidisciplinary assessment and treatment, on March 15, 2013.

But by that stage, according to Mr Barnes, Mr Wotherspoon was already “in crisis”.

And three weeks later, after a number of unexplained administrative errors, he was still in the MHU at Cessnock Correctional Centre.

“The failure to transfer David to the MHSU in the three weeks from when his treating psychiatrist ordered that to occur until the fatal incident was a significant omission by those responsible within Justice Health.”

Mr Wotherspoon appeared to be acting rationally in the minutes before he was found unconscious, prompting Mr Barnes to conclude that he must have undergone a “sudden mood change that led to him deciding to take his own life”.

Mr Wotherspoon had been trying to cover a camera in his cell with wet toilet paper from about 3.06pm on April 5, 2013.

He failed a number of times, the toilet paper sliding off onto the ground, before he managed to partially cover the camera looking into his cell about 3.15pm.

He could still be seen moving around on the cameras up until 3.20pm.

But by the time two correctional officers went to deliver his meal at about 3.35pm he was unconscious, a ligature tied tightly around his neck.

During the inquest, the monitoring room officer said she wasn’t exactly sure why she missed the camera being partially covered up and Corrective Services Investigation Unit Detective Inspector Garry James said the role of monitoring officer at the jail was too onerous for one person.

Mr Barnes agreed and noted that since earlier this year, two officers have been posted in the monitor room and a standard operating procedure had been implemented.

He said these changes adequately addressed the shortcomings in Mr Wotherspoon’s case.

But he was critical of Corrective Services officers and Justice Health staff responsible for managing the MHU, who he said failed to conduct a careful risk assessment of what personal items Mr Wotherspoon could have in his cell.

“The management of such inmates requires balancing the risk they pose to themselves and others against the detrimental effect of minimising those risks by intensive observation and the withdrawal of access to personal items that can be used to self-harm,” Mr Barnes said.

“That careful assessment did not occur in this case.

“No one made a considered assessment that the risk of allowing David to have access to ligatures was justified.

“This was a failure of the correctional officers and Justice Health officers responsible for managing the MHU.”

When determining the adequacy of Mr Wotherspoon’s mental health care, Mr Barnes noted that independent psychiatrists who reviewed the case were of the view that Mr Wotherspoon’s level of care was appropriate.

“However, it is notable that two of the practitioners who sought to provide care to David while he was in the MHU withdrew from their respective roles as a result, it seems, of their dissatisfaction with the circumstances in which care was expected to be provided,” Mr Barnes said.